New recommendations published in Epileptic Disorders proposed by a global group of experts provided a robust and uniform definition framework for different types of seizures as well as guidelines for early treatment to prevent progression to seizure emergencies. These recommendations complement the existing guidance for the management of acute seizures, emphasizing that earlier treatment may potentially avoid progression to more severe seizures, including status epilepticus.1,2
The working group of experts, comprised of 12 epileptologists, neurologists and pharmacologists from Europe and North America, conducted a literature review to identify relevant publications that related to the characterization of prolonged seizures and seizure clusters, the associated burden to patients, caregivers, and the healthcare system, and current management. Experts reviewed 205 studies identified from both MEDLINE and Embase databases published between January 2009 and May 2022 on epidemiology, disease burden, clinical outcomes, and guidelines relating to prolonged seizures and seizure clusters.
“It is essential that we prevent seizures from progressing to more severe and complex types which result in significant physical, psychological, cognitive and socioeconomic burden for patients, caregivers and healthcare systems alike,” Jesus Eric Pina-Garza, MD, cochair of the Seizure Termination Project and director of Pediatric Epilepsy at Centennial Children’s Hospital, said in a statement.2
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Top Clinical Takeaways
- Early intervention is crucial to prevent seizures from progressing to more severe forms, reducing the burden on patients, caregivers, and healthcare systems.
- The new guidelines propose specific time thresholds for different types of prolonged seizures and define seizure clusters based on individual patient patterns.
- Consensus on the recommendations was achieved through a multi-step modified Delphi approach, emphasizing the importance of expert agreement in clinical practice guidelines.
Experts used a multi-step modified Delphi approach to develop and anonymously vote on consensus recommendations. For voting, experts could select from 5 options: “strongly agree,” “agree,” “disagree,” “strongly disagree,” or “unable to answer.” Consensus was defined as an achievement of at least 75% vote from the exert working group of “strongly agree” or “agree.” The group of experts all had at least 10 years of clinical or research experience in epilepsy in academic hospitals (n = 9), general/community hospitals (n = 1), research (n = 2), and private practice (n = 1) settings. Among those who currently saw patients (n = 11), 7 reported that they saw over 100 patients per month, and 8 reported that more than 50% of their patients had epilepsy.
Based on the literature reviewed, all the experts agreed strongly that an ideal treatment for rapid and early seizure termination (REST) would start to act in 2 minutes of administration to stop ongoing seizure activity. This timeframe was derived from the short window of opportunity in which to terminate the seizure before it becomes prolonged or progresses to a tonic-clonic phase, or status epilepticus.
Experts also reached this consensus by terminology that defined status epilepticus and seizure clusters. Prolonged seizures were defined as proposed thresholds of 5 minutes for prolonged focal seizures and 2 minutes for prolonged absence seizures and the convulsive phase of bilateral tonic-clonic seizures. Seizure clusters were defined as an abnormal increase in seizure frequency compared with the individual patient's usual seizure pattern.
“Providing a clearer picture for clinicians, patients, and caregivers, on how and when to effectively treat prolonged seizures through the introduction of the concept of REST is an important step forward in disease management which will help to facilitate improved outcomes for patients and reduce healthcare resource utilization,” Pina-Garza said in a statement.1
All of the expert group members also strongly agreed or agreed that patients who experienced a prolonged seizure should be offered a REST treatment option, and all patients who experienced a seizure cluster should be offered an acute cluster treatment (ACT). Furthermore, they strongly agreed or agreed that when prescribing a REST medication or ACT, a seizure action plan should also be agreed upon in consultation with both the patient and their caregiver. The working group members also agreed that the main consideration when prescribing a REST medication would be safety and/or tolerability.
REFERENCES
1. Pina-Garza JE, Chez M, Cloyd J, et al. Outpatient management of prolonged seizures and seizure clusters to prevent progression to a higher-level emergency: Consensus recommendations of an expert working group. Epileptic Disord. Published online May 30, 2024. doi:10.1002/epd2.20243
2. Global experts release new guidelines on prevention of progression of epileptic seizures, addressing critical treatment gaps. News Release. Published June 10, 2024. Accessed June 12, 2024. https://www.ucb.com/stories-media/Press-Releases/article/Global-experts-release-new-guidelines-on-prevention-of-progression-of-epileptic-seizures-addressing-critical-treatment-gaps
